Integrating

Pharmaceutical
Care:
A Vision
and Framework
Written by
Deborah Paone
Richard Levy
Richard Bringewatt

National National
Chronic Care Pharmaceutical
Consortium Council
2 The National Chronic Care Consortium and The National Pharmaceutical Council
The National Chronic Care Consortium
(NCCC) and the National
Pharmaceutical Council (NPC)
jointly developed this vision and
framework for integrated
pharmaceutical care.

The National Chronic

Care Consortium
The NCCC is an alliance of the nation’s
leading nonprofit health systems and
serves as a national operational labora-
tory for developing and testing models
and methods to improve care for people
with chronic conditions. The NCCC also
serves as a national resource center in
transforming delivery systems to
Contents
improve quality and reduce costs of
standard operating procedures used by Executive Summary..............................................................3
purchasers, payers, and providers.

National Chronic Care Consortium Introduction ......................................................................... 4

8100 26th Avenue South
Suite 120
Bloomington, MN 55425 Section 1: The Need for Integrated Pharmaceutical Care
(612) 858-8999
Fax: (612) 858-8982
Pharmaceutical Care Challenges ............................... 6
www.nccconline.org The Changing Role of Pharmacy Services .............. 8

The National Pharmaceutical The Nature of Chronic Conditions ........................... 9

Council
NPC is an educational association
supported by the leading research- Section 2: Implementing Integrated Pharmaceutical Care
based pharmaceutical companies. NPC
demonstrates and communicates the The Vision ................................................................... 12
scientific, clinical, and societal value of
evidence-based healthcare, including The Framework: A Systems Solution..................... 15
pharmaceuticals. NPC works with
public and private sector partners to Benefits of Integrated Pharmaceutical Care ......... 19
implement research and demonstration
projects related to the optimal use of Case Studies ................................................................ 20
pharmaceuticals.
Taking Action.............................................................. 24
National Pharmaceutical Council
1894 Preston White Drive
Reston, VA 20191-5433 References .......................................................................... 26
(703) 620-6390
Fax: (703) 476-0904 © Copyright 1999 by the National Chronic Care Consortium
www.npcnow.org. and the National Pharmacetical Council. All rights reserved.

Integrating Pharmaceutical Care: A Vision and Framework 3

Executive Summary
Chronic disease is widespread in the United States, particularly among the elderly,
and is accompanied by complex clinical and psychosocial dimensions. The elderly
are especially at risk for receiving ineffective treatment or suboptimal care, which
leads to adverse consequences. This situation is produced in part by a fragmented
healthcare system that often ignores the need to integrate pharmaceutical care with
other aspects of chronic conditions.

Multiple medications are often prescribed and managed separately and are not
coordinated across disease states or care settings. Additionally, the financial
incentives of service sites and providers often are not aligned with the objective of
using pharmaceuticals to manage overall treatment outcomes and costs. This
fragmentation of care increases the potential for suboptimal prescribing, drug
interactions and adverse effects, duplicate prescriptions, and noncompliance with
treatment regimens. In light of these problems—and since pharmaceuticals are the
central element in the treatment of chronic care patients—it is important to consider
an approach to pharmacotherapy that is focused on the totality of care.

Integrated pharmaceutical care is not about an increase or decrease in use of

pharmaceuticals; it is about enabling appropriate pharmaceutical management as an
integral component of primary, acute, and long-term care services. This paper
describes a systems-based model for pharmaceutical care that is based on the belief
that the full value of pharmaceutical therapy is best achieved when care is organized
around the person, focuses on disability prevention and health maintenance, and
extends smoothly across settings, across providers, and over time. The model
specifies support for the program by senior management and a multidisciplinary
team approach to the ongoing management, coordination, and evaluation of
medicines. Care decisions are supported by information systems that track
prescriptions and provide feedback on the results of therapy.

In keeping with this model, selection of pharmaceuticals and treatment plans are
tailored to the needs of individual patients and based on overall treatment outcomes
and cost. Selection criteria also include the medication’s ability to improve the
performance of daily activities, slow the progression of disability and dependence,
and facilitate compliance. Selection also recognizes ethnic and cultural differences
among patients, especially attitudes and beliefs about medications that may make
the difference between successful and unsuccessful treatment. Since this model of
pharmaceutical care is responsive to the prevailing characteristics of chronic disease,
it should result in improved clinical outcomes, quality of life, and patient
satisfaction. Additionally, the inherent efficiencies of this approach may be especially
attractive to provider organizations that assume overall risk for a defined population
group.

This paper presents examples of organizations’ successes in implementing

pharmaceutical integration, along the lines of the model. The NCCC and NPC also
have tools available that specify criteria and measures for integrated pharmaceutical
care and help organizations to assess their current extent of integration. These may
be useful in assisting organizations in strategic planning for pharmaceutical
integration.

4 The National Chronic Care Consortium and The National Pharmaceutical Council
 Introduction
The National Chronic Care Consortium (NCCC) and the National Pharmaceutical
Council (NPC) jointly developed this vision and framework for integrated
pharmaceutical care. This vision and framework are based on the belief that the full
value of pharmaceutical care in the treatment of chronically ill patients is best
achieved in a truly integrated setting. The concepts in this paper derive from the
commitment of both organizations to an integrated, population-based, and holistic
approach to healthcare. The cost efficiencies and potential for improved care inherent
in an integrated approach will become important as payers increasingly demand that
provider organizations deliver quality care while assuming overall risk for
populations.

Integration is not about an organization’s contractual or ownership arrangements.

Rather, it is a way of organizing and implementing the care process. Integration
methods can be adapted to a wide range of delivery systems, alliances, and
partnerships. As the NCCC and NPC conceive it, integrated care is organized around
the individual, focusing on health maintenance and disability prevention across time
and settings. Individuals and populations served by a healthcare system organized
according to these principles will enjoy better clinical, social, and cost outcomes.
Integrated healthcare differs from disease management, especially in its application
to chronic illness.

The term “disease management” has been applied to many activities that represent
important advances beyond episodic and uncoordinated care. But a disease-by-
disease approach may neglect interactions between diseases and often does not
address the potential for overall health management offered by a population-based
approach. Health management involves prevention, diagnosis of undetected disease,
and minimization of disease risk. It requires the alignment of economic incentives
and a sharing of the financial risks among all providers and service sectors in the
system (Gevirtz et al.,1999).

The NCCC defines people with serious and persistent chronic conditions as those
who “…possess one or more biological or physical conditions where the natural
evolution of the condition(s) can significantly impact a person’s overall quality of
life, including an irreversible inability to perform basic physical and social functions”
(Bringewatt, 1995). These individuals represent the highest-cost, fastest-growing
segment of the population served by healthcare organizations. Unfortunately, the
current cure-oriented healthcare system is not designed to serve these patients.
Current administration and financing programs perpetuate a fragmented,
institution-based approach. Chronic care patients have sustained needs but are
served by “…a system of care that is in fragile equilibrium. Even slight perturbations
in their support system can have direct consequences and also secondary or
compensatory effects” (Soumerai et al., 1994). A more population-based, integrated
approach is required to provide needed stability and optimal care for these patients.
Since pharmaceuticals are a key treatment strategy for most chronic care patients,
this paper discusses the need for and the value and characteristics of a system where
pharmaceuticals are fully integrated into overall patient care.

Integrating Pharmaceutical Care: A Vision and Framework 5

 Section 1:
The Need for
Integrated
Pharmaceutical Care
Pharmaceutical innovation has greatly improved treatment
outcomes and quality of life for patients with many chronic
conditions, including HIV/AIDS, diabetes, depression,
psychosis, ulcer, and cardiovascular disease. However, there is
evidence that medication management in the chronic care
population could be improved.

This section examines current pharmaceutical care challenges,

explores the evolution of pharmacy services, and reviews the
characteristics of chronic conditions. It is these characteristics
of chronic conditions need to drive the delivery of
pharmaceutical care.

6 The National Chronic Care Consortium and The National Pharmaceutical Council
 Pharmaceutical Care Challenges
Medications have become the most common therapeutic intervention in modern
healthcare (Evans et al., 1994) and represent a major form of treatment for elderly
individuals and others with chronic conditions. Although the elderly comprise 12
percent of the population, they account for 34 percent of total pharmaceutical
expenditures (Mueller et al., 1997). There are several significant challenges to
providing pharmaceutical care for older adults and people with chronic conditions.

Component Management
Perhaps the most important factor contributing to suboptimal use of medications in
the chronic care population is that—even in “integrated” healthcare systems—
medications are often managed separately from other elements of care, and drug
therapy is not coordinated across disease states or care settings. Some observers call
this “component management,” with a characteristic focus on just one piece of
healthcare at a time (Cohen and Naughton, 1995). Component management of drug
therapy, where selection of pharmaceuticals occurs without knowledge of the overall
effect on the patient, can result in compromised clinical outcomes and increased use
of medical services (Horn et al., 1998; Levy and Cox, 1999; Soumerai et al., 1991,
1994). This lack of coordination also increases the potential for drug interactions,
duplicate prescriptions, noncompliance, suboptimal prescribing, and over- and
under-treatment. Additionally, the financial incentives of the various sites or
providers often are not aligned. There is rarely an overarching goal that drives care
decisions.

Underuse and Overuse of Pharmaceuticals

There is evidence that many older adults may be taking too many prescription and
over-the-counter medications. While the appropriate medications may have
significant positive effects, polypharmacy (multiple medications, e.g., eight or more)
can lead to an increased incidence of drug-to-drug interactions, more adverse drug
events, a decrease in medication compliance, and, potentially, a decline in quality of
life (Stewart and Cooper, 1994). Underuse of pharmaceuticals in chronic care patients
with multiple concurrent illnesses also has been documented. One disease may be
neglected if another disease receives primary attention. For example, one study
found that older patients with diabetes, pulmonary emphysema, or psychotic
syndromes received as many as 60 percent fewer prescriptions or other treatments
for concurrent but unrelated diseases (estrogen replacement therapy, lipid lowering
medications, and medical treatment for arthritis, respectively) compared with
patients with only one disease (Redelmeier et al., 1998). Such problems may be
widespread since it is estimated that more than 40 percent of people with chronic
illness have more than one chronic condition (Robert Wood Johnson Foundation,
1996).

Inappropriate Prescribing and Adverse Reactions

Problems of inappropriate prescribing and adverse reactions among the elderly have
been well-documented (Baum et al., 1984; Stewart and Cooper, 1994; Wilcox et al.,
1994; General Accounting Office, 1995). The incidence of adverse drug reactions is
high—estimates vary from five percent to 35 percent. Medication use in older adults

Integrating Pharmaceutical Care: A Vision and Framework 7

tends to rise with age (Stewart et al., 1991), and age-related changes in physiology
can alter the effectiveness, time course, or side effects of many drugs (Lindley et al.,
1992). Additionally, the use of multiple medications, especially by patients with
several conditions, can increase the risk of adverse effects. Studies of adverse drug
events occurring in patients admitted to tertiary hospitals revealed that drug errors
can be due to a physician ordering the wrong dose or choosing the wrong
medication. More often, however, injuries result from systems problems arising from
the complex interactions among individuals, as well as from problems in dealing
with sophisticated technologies (Leape et al., 1995; Hendee, 1998).

Lack of Coordination of Information

There is also the problem of coordinating information. A patient may go to several
different specialists, and these physicians may each prescribe a medication for the
symptom or problem that they are treating. Unfortunately, these physicians may
have incomplete information about the full set of medications that the patient is
taking. In addition, there may be problems in getting timely information to the right
provider. In a study of adverse drug events in two hospitals, many errors were due
to incomplete or inaccurate patient information. Results of laboratory tests, current
medications, or information about the patient’s condition were sometimes not easily
accessible when needed, which resulted in prescribing errors. Pharmacists, too,
sometimes lacked critical information that would have allowed them to stop an
improper order (Leape, et al., 1995).

Adherence to Medication Regimens

Adherence to medication regimens can be a major problem for chronic care patients.
The regimens may require frequent administration of several different medications.
Older people with cognitive difficulties may be less able to follow medical advice,
ask for clarification, or actively participate in self care. Due to their frailty, older
people can be particularly susceptible to the physical, social, and psychological
consequences of nonadherence to medication regimens (Balkrishnan, 1998).
Medication adherence rates for the elderly range from 26 percent to 59 percent
(Balkrishnan, 1998). Some studies have shown that the greater the number of
medications prescribed for elderly patients, the greater the rate of noncompliance
(Col et al., 1990; Coons et al., 1994). Consequences of elderly patients’ nonadherence
to medication therapy include reduced effectiveness or treatment failure, disease
progression, emergence of resistant bacteria, medication overdose, unnecessary
medical expenses, and hospitalizations (Greenberg, 1984). In one study,
approximately 11 percent of hospital admissions in an elderly population were
related to medication noncompliance (Col et al., 1990).

Balancing Costs
The last few years have witnessed a significant increase in the number of
medications available and a rise in the relative proportion of medication costs
compared to total healthcare expenditures. This is clearly a concern to healthcare
providers and plans. There is some evidence, however, that the strategic
employment of newer pharmaceuticals can leverage overall treatment costs.
When they offer substantial therapeutic advantages over existing therapies, new
medications may reduce utilization and costs of other services, and reduce overall
costs associated with disability and labor (see for example Cystic Fibrosis
Foundation, 1993; Fagan et al., 1998; Legg et al., 1997a, b; Peters, 1993; Stocker, 1996).
8 The National Chronic Care Consortium and The National Pharmaceutical Council
 The Changing Role of Pharmacy Services
Within the last decade we have seen an evolution in the organization of pharmacy
services within healthcare institutions. The number of stand-alone facilities has
diminished, as the number of larger multiorganizational systems and alliances has
increased. Many multiorganizational healthcare systems began as hospitals or
physician groups and grew through mergers and acquisitions of other local
healthcare facilities. Often, each new facility added to the system brought its own
management structures and procedures for selecting, ordering, distributing, and
evaluating pharmaceuticals. It was not uncommon for the pharmacy services
departments at each institution to operate relatively independently from one
another for years.

To realize the operating efficiencies and clinical improvements made possible by

consolidation, many of these newly integrated systems are beginning to integrate
pharmacy operations across service sectors. One challenge to planners seeking
operational efficiencies is to assure that an adequate range of drugs for individuals
or groups of patients with specific clinical needs is available at a given site.

With the evolution in healthcare systems has come a change in the role of
pharmacists working in these systems. Traditionally, pharmacy was a hospital
ancillary service; pharmacists ordered and dispensed medications, managed a
formulary for a hospital or physician group, reinforced instructions to patients on
prescribed medications, and occasionally consulted or advised clinicians (Ogden et
al., 1997). Pharmacists, especially hospital pharmacists, have been advocating for a
greater clinical role in “a more integrated approach for drug distribution and
provision of services” (Pierpaoli et al., 1986). While the physician remains the
primary decisionmaker regarding therapy for individual patients, the advent of
complex healthcare systems has given rise to a greater role for pharmacists in the
management of pharmaceuticals.

Integrated pharmaceutical care means new roles for pharmacists. In 1997,

pharmacists in integrated health systems (including managed care organizations)
were found to be spending approximately 45 percent of their time on dispensing
functions, 30 percent on clinical activities, and 21 percent on administrative
responsibilities (Reeder et al., 1998). These pharmacists reported that they are
increasingly able to participate in activities representing elements of integrated
pharmaceutical care. Such activities include report card development, population-
based decisionmaking, quality performance assessment, physician education,
medication compliance monitoring, use of pharmacoeconomic data for formulary
decisionmaking, and patient counseling. Pharmacists also were often included on
interdisciplinary teams for ambulatory patients (Reeder et al., 1998). Case studies
that highlight the expanded institutional roles of pharmacists are presented on
pages 20 to 23.

Integrating Pharmaceutical Care: A Vision and Framework 9

The Nature of Chronic Conditions
The NCCC defines people with serious and persistent chronic conditions as those
who “…possess one or more biological or physical conditions where the natural
evolution of the condition(s) can significantly impact a person’s overall quality of
life, including an irreversible inability to perform basic physical and social
functions” (Bringewatt, 1995).

Chronic diseases are multidimensional, involve psychosocial factors, and are

interdependent with other acute or chronic diseases the patient may have. Further,
chronic diseases are often disabling and continue over long periods of time. To
reduce costs and increase quality over the long term, management infrastructures
must be more responsive to these characteristics. Since pharmaceuticals play such a
large role in the treatment of chronic care patients, the organization of pharmacy
services must take these characteristics into account.

Because current healthcare policy, regulation, and payment methods were designed
with short-term medical problems in mind, people with chronic diseases and
disabilities remain one of the most challenging groups served by healthcare
providers. These characteristics of chronic conditions need to drive the delivery of
pharmaceutical care.

Multidimensional
Most care delivery organizations are organized primarily to stabilize body chemistry
through pharmaceutical and medical technology. However, chronic illness also
includes functional, emotional, social, and environmental concerns. Effective care
requires attention to these nonmedical dimensions. Thus, selection of
pharmaceuticals for individual patients should take into account the effect on a
person’s function, attitude, and lifestyle. Pharmaceutical regimens should be
prescribed with an understanding of a person’s views about healthcare and with a
realistic expectation of adherence to the regimen.

Interpersonal
Chronic conditions often affect every aspect of a person’s life and identity. The
power of personal values, the influence of family and friends, and the importance of
community are strong factors in the health and function of each individual.
Healthcare providers and systems need to understand these influences and provide
support for family caregivers. Recognition by providers of language barriers and
cultural differences among patients, especially regarding attitudes and beliefs about
drug therapy, can make the difference between successful and unsuccessful
treatment.

Disabling
Medical concerns generally dominate care decisions, but from the patient’s
perspective the primary issue of chronic illness is retaining function. Accordingly,
treatment needs to be focused on preventing, delaying, or minimizing the
progression of disability. This requires an understanding of the natural evolution of

10 The National Chronic Care Consortium and The National Pharmaceutical Council

Chronic Care Facts
Individuals with chronic
conditions represent the highest-
cost, fastest-growing segment of
the population served by
healthcare organizations.
• In 1995, an estimated 99
million people in the United
States had a chronic condition,
characterized by persistent
and recurring health problems
lasting for an extended period
of time.
• Though people with chronic
conditions represent only 20
percent to 30 percent of the
entire population served by a
healthcare system, they incur
more than 70 percent of the
costs.
• Chronic conditions are the
leading cause of illness,
disability, and death in the
United States today, and are
responsible for 90 percent of
all morbidity and 80 percent
of all deaths.
• Chronic conditions constitute
70 percent of the nation’s
personal healthcare
expenditures.
• In 1987 dollars, the average
annual per capita cost for
persons with one or more
chronic condition was $4,762.
• In the next 25 years, the
number of Americans with
chronic conditions will
increase by approximately 35
million.
(Source: Chronic Care in America,
A 21st Century Challenge, Robert
Wood Johnson Foundation,
1996)
Integrating Pharmaceutical Care: A Vision and Framework
chronic conditions, the risk factors associated with next-phase
disability progression, and those pharmaceutical and other
interventions which reduce the probability of future care
needs. Providers should assess treatment outcomes in terms of
functional status as well as health status, and payment
systems should support both. Improved payment systems that
reward disability prevention encourage the use of
pharmaceuticals, which improve function. Such drugs,
especially those that improve mobility or cognitive ability, can
slow disability progression and improve function and quality
of life.
Interdependent
The needs of chronic care patients are highly interrelated, yet
financing and delivery of care often occurs through a plethora
of isolated contracts, regulations, providers, and staff. Often
scant attention is given to how multiple but uncoordinated
interventions affect cost and care outcomes. Multiple diseases
are common in chronic care patients, and interrelationships
among diseases often complicate care management. Optimal
prescribing for these patients requires input from an
interdisciplinary team of caregivers. Contracts with provider
networks or alliances should include incentives that enable
practitioners who serve the same person to work together in
achieving common cost and quality outcomes.
Ongoing
Unfortunately, policymakers and payers focus primarily on
reducing costs care component by care component, as if
hospitals, home health agencies, nursing homes, and
pharmacy services were unrelated businesses, with no sense
of the cumulative effects of ongoing chronic care interventions
on cost and quality over time. Current training and
compensation for providers is often focused on responding to
a medical circumstance or crisis event, disregarding care needs
that extend over time. The ongoing nature of chronic
conditions must be acknowledged through a more
longitudinal perspective on the management, cost, and
evaluation of the pharmaceutical care provided to people with
chronic conditions.
11
 Section 2:
Implementing Integrated
Pharmaceutical Care
Pharmaceutical care is central to the overall treatment and
ongoing management of chronic conditions, and therefore
pharmaceutical services must be organized and delivered in
concert with the continuum of care. Integrated
pharmaceutical care is not about an increase or decrease in
use of pharmaceuticals; it is about enabling appropriate
pharmaceutical management as a integral component of
primary, acute, and long-term care services. This section
provides a vision for integrating pharmaceutical care and
includes a framework for organizations to create a systems
solution in addressing care challenges. This section also
describes the benefits of integrated pharmaceutical care,
provides examples of organizations’ successes, and offers
steps for moving ahead.

12 The National Chronic Care Consortium and The National Pharmaceutical Council
 The Vision
Optimal care of the chronically ill in both public and private-pay programs requires
moving from reducing costs for defined programs to exploring incentives and
oversight functions that can enable the establishment of a new generation of care in
keeping with the nature of chronic illness. The NCCC and NPC’s vision for the
healthcare delivery system of the future is one where care is organized around the
multidimensional needs of the person, is focused on disability prevention, and
extends across time, place, and setting. For people with chronic conditions, the
coordination of services in this way is not a luxury but a necessity.

The organization, management, and delivery of pharmaceutical care should support

the goal of continuity of care—this is particularly important for older adults and
those with chronic conditions who require care from several providers. Consider the
characteristics of chronic conditions listed below and how the healthcare delivery
system can reorganize pharmaceutical care to mirror these characteristics.

Characteristics of Implications for

Chronic Conditions Pharmaceutical Care
Multidimensional ➤ The choice of medications should recognize
The illness affects the whole person. psychological and social factors as well as
biological and lifestyle factors. Medication
regimens should be monitored to determine
overall effects on these dimensions.

Interpersonal ➤ The overall effects of pharmaceutical

The illness affects and is affected by treatment should enhance, or at least not
family and friends. impede, a person’s ability to perform social
roles and to derive benefits from family/
friend relationships.

Disabling ➤ Pharmaceutical treatment should seek to

The illness can significantly affect a person’s prevent, delay, or minimize disability
ability to carry out the most basic daily prevention and should not impair
activities. performance of important activities of daily
living or result in further dependence.

Interdependent ➤ Medications given for one disease can

Care is often complicated by interrelation-
ships among multiple conditions.
enhance or minimize the effects of
medications given for another disease.
Thus, the course of treatment should take
into account comorbidities and drug
interactions.

Ongoing ➤ Medication records should follow the

The illness does not disappear after a few
office visits or a hospitalization.
patient across sites and providers.
Continuity of care should be supported
through communication processes and team
management. Improving the health and
well-being of a person over the long term
should be a goal of pharmaceutical care.

Integrating Pharmaceutical Care: A Vision and Framework 13

The NCCC and NPC have recognized two important aspects of providing optimal
pharmaceutical care within a care delivery system.

First is the organization of pharmacy services within and across care delivery sites,
which influences how pharmaceuticals are ordered, distributed, and evaluated. This
includes an infrastructure that allows the organization to track prescriptions and
treatment outcomes.

Second are the processes whereby medications are prescribed, used, monitored, and
determined to be effective for a given patient or group of patients. This includes a
feedback loop to prescribers and other care managers to monitor effectiveness and
evaluate the need for modification of the treatment.

Integrated Pharmaceutical Care Principles

Healthcare organizations may wish to adopt the following principles for integrating
or reorganizing their pharmaceutical care services.

1. Pharmaceutical care is an integral part of any continuum of services offered by a

healthcare organization.

2. The effect of pharmaceutical care, in combination with other services or

treatments, optimizes functional and medical outcomes of those served and
prevent, delay, or minimize disability progression.

3. Pharmaceutical care policy/practice supports continuity of care across settings.

Settings and providers pursue a common set of pharmaceutical care objectives to
optimize cost, quality, and satisfaction outcomes.

4. High-risk patient groups warrant special attention by the healthcare system

related to medication use, prescribing patterns, efficacy of pharmaceuticals, and
compliance.

5. Outcomes associated with an integrated pharmaceutical care approach are

measured.

6. Pharmaceutical care decisions are integral to comprehensive care plans. Care

plans take into account the multidimensional nature of clients served.

7. The approach to pharmaceutical care for an individual responds to the changing

dynamics of a person’s condition.

8. People who are responsible for deciding, ordering, distributing, administering,

monitoring, and evaluating pharmaceutical care are expected to function as part
of a common care team.

9. Clients and their families are important partners in medication management. The
healthcare organization promotes this role through information, training and
education on self care, wellness, disease characteristics, and proper use of
medications.

14 The National Chronic Care Consortium and The National Pharmaceutical Council
 10. The structure of pharmacy services and how they are organized within a
multiorganizational delivery system promotes cross-site communication and
decisionmaking on pharmaceutical care across the system.

11. Leadership and support from the highest management and governance levels of
the organization is necessary to ensure that the quality of pharmaceutical care is
high.

12. Pharmaceutical information is a part of a comprehensive set of information on

clients to understand medical, functional, and psychosocial needs.

13. All necessary information on medications is available to practitioners across

settings when they need it, with appropriate safeguards to maintain client
confidentiality.

14. Financial incentives of providers related to pharmaceutical care are aligned to

promote and optimize cumulative clinical and economic outcomes across the
system.

15. The system takes a long-range view when determining the cost effectiveness of
pharmaceuticals.

16. The healthcare system is aware of rules and regulations of public and private
purchasers related to pharmaceutical care and of limitations in the pharmacy
benefits of clients’ health insurers. The healthcare system works to minimize
adverse effects and maximize positive opportunities arising from these rules,
regulations, and benefit structures.

Integrating Pharmaceutical Care: A Vision and Framework 15

The Framework: A Systems Solution
Integrated pharmaceutical care must be part of a systems solution. Simply changing
practice guidelines or creating new protocols will not achieve the desired patient
care results. The problems are systemic and intertwined; therefore, basic changes are
required in the infrastructure and organization of the healthcare delivery system, as
well as in clinical practice. NCCC’s vision of an integrated approach to care,
including pharmaceutical care, involves four components of integration:
governance/management of the organization, clinical management of patients,
information systems, and financing through payment and reimbursement systems.

Governance and Management

Many senior executives of healthcare organizations are encumbered by
organizational structures, governing bodies, and system performance measures that
are out of step with future care requirements and expectations. Meeting the chronic
care challenge requires redefining the governance and management of health
systems to reflect a new vision of care. This includes changing board composition,
accountability measures, reporting relationships, and staff performance incentives.
In pharmaceutical care, this translates to leadership and support for an integrated
approach across the various sites of care in the system to ensure that ongoing patient
needs are met. Thus, the structure and organization of pharmacy services would
promote cross-site communication and decisionmaking about pharmaceutical care
across the system. There must be accountability for how pharmaceuticals are
managed and provided to customers, at the highest level of system governance,
with special emphasis on chronic care populations. Other characteristics of an
integrated system related to governance and management of pharmaceuticals
include

• A management structure that includes assignment of responsibility for providing

caregivers with the tools required for an integrated pharmaceutical approach

• Management and clinical leadership that ensures necessary training in an

integrated approach to pharmaceutical care

• An emphasis on the use of pharmaceuticals in primary and secondary prevention

to prevent clients from becoming high-risk patients

• Considerations of epidemiological factors in the care of individuals, including

demographics, disease incidence, and prevalence in populations and
subpopulations, especially in high-risk patients

• A structure for systemwide monitoring of medication effectiveness and treatment

outcomes

• Evaluations of new drugs or treatment regimens and a review of existing drugs,

policies, and procedures for effectiveness

16 The National Chronic Care Consortium and The National Pharmaceutical Council
 Clinical Management
The goal of integrated care management is that care provided in different settings at
different times and by different professionals to support common patient and
system goals. To achieve this, organizations need to establish seamless continuums
of care, including the full spectrum of primary, acute, and long-term care services. If
providers create and implement care plans that recognize the multidimensional
aspects of disease, patients moving between care settings will not experience
discontinuity. Practitioners will understand the risk factors associated with disease
and disability progression and will develop protocols that prevent, delay, or
minimize disability progression and the future need for high-cost services. Key
characteristics of an integrated approach to pharmaceutical care management
include

• Effective methods for population-based management of conditions, particularly

where therapy depends heavily on pharmaceuticals

• Care plans that account for the multidimensional nature of clients served

• Early identification of changes in a person’s condition, diet, lifestyle, or use of

nonprescription drugs that could affect response to prescribed medications—
these changes are monitored and prescribed treatments are altered if necessary.

• Prospective identification of high-risk individuals—upon identification,

pharmaceutical therapy is initiated or changed to avoid adverse outcomes

• Prescribers and pharmacists function as part of a care team.

• Providers and care managers work effectively to avoid delays or interruptions in

providing pharmaceutical treatment and are supported in managing
pharmaceutical care across settings/sites of care and over time.

• Providers inform patients about pharmaceutical options and understand the

effects of prescribed medication and its interaction with diet, exercise, and
nonprescription drugs. Patients are actively involved in choosing a course of
treatment.

• Providers actively seek patients’ perspectives in evaluating the effectiveness of

pharmaceutical care. Satisfaction with specific pharmaceutical regimens is
assessed, and this information is used in prescribing decisions and modifications
to treatment protocols.

• Providers and care managers regularly monitor compliance with medication

regimens. For clients at risk for noncompliance, the clinical team works with the
client and caregivers to modify the regimen or address the issues underlying
noncompliance.

• The organization educates staff on health beliefs and cultural norms of various
ethnic, culturally defined, and age groups, especially regarding beliefs about the
role of pharmaceuticals in maintaining or improving health status.

Integrating Pharmaceutical Care: A Vision and Framework 17

Information Systems
The potential of information systems technology far exceeds applications that most
healthcare organizations have in place today. Although organizations may collect
key clinical, demographic, service use and financial data on an individual patient or
set of patients, this information resides in different databases and at separate sites.
In general, organizations are not currently able to link the data sets —and thus they
cannot accurately identify the outcomes or costs of any specific chronic disease or
disability over the course of treatment. Providers often cannot access important
information in “real time” when it would be most useful in decisionmaking.
Pharmaceutical care information may be incomplete or may reside in the separate
database of each service sector (inpatient, hospital, physician clinic, ambulatory
care, home health agency, nursing facility, or retail pharmacy).

The need to measure outcomes of care is more urgent than ever. The ability to track
and coordinate pharmaceutical use as patients move across the system is a
necessary component of integrated care. This ability is also necessary if new
therapies and care approaches are to be appropriately evaluated and used to
achieve optimal care and cost savings. Unfortunately, most delivery organizations
have not yet linked their pharmacy data with patient-level information from other
services, such as hospital admissions, laboratory data, and office visits. The ability
of health plans to link this data is important for implementation of fully integrated
pharmaceutical care.

In an integrated system, pharmaceutical care information would be part of a

comprehensive database that would help providers understand clients’ medical,
functional, and psychosocial needs. All necessary information on medications
would be available to practitioners across settings with appropriate safeguards to
maintain client confidentiality. Key characteristics of an integrated information
system include

• The ability to integrate medical cost and utilization data with pharmacy data and
to track and report aggregate trends in outcomes over time and across settings

• The ability to generate client-specific reports showing care over time—for

example, a record of the client’s entire medication profile shown over time and
across settings

• The ability of all care providers and prescribers to access necessary medication
information

• The ability to identify potential drug interactions and to trigger actions by

physicians and other prescribers proactively

Full and immediate integration of information systems is not a realistic objective for
most organizations. It is a lengthy and expensive process, which should be
undertaken incrementally. A key step for integrating pharmaceutical care, however,
is the ability to link patient-level prescription data with utilization data for other
services. The cost of making this link may not be as high as implementing a fully
computerized patient record.

18 The National Chronic Care Consortium and The National Pharmaceutical Council
 Financing
Services for people with chronic conditions are financed by multiple public and
private sources, each using a different approach to program administration.
Unfortunately, the current financing and administration of government-sponsored
programs often have the unintended effect of locking in place a fragmented,
institution-based, cure-oriented approach to care. Medicare, Medicaid, and many
other programs frequently provide disincentives for third-party payers and
providers to take a holistic, longitudinal approach to chronic care. Even within
managed care programs, costs and quality of care are often managed through a
series of cost or discount-based subcontracts with providers—reducing the potential
for shared incentives or common goals across sites of care. Proper management of
chronic conditions will require a shift in the focus of financing and an alignment of
incentives to achieve benefits that are cost-effective to purchasers of care.

Key characteristics of an integrated approach to pharmaceutical financing include

• The healthcare system’s contracts and provider payment methods include

incentives for providers to manage pharmaceuticals across settings and over
time, basing reimbursement on providers’ ability to impact care and cost out-
comes according to system-wide cumulative care and cost goals. Contracts with
aligned financial incentives for medication management across sites of care cover
an increasing proportion of the healthcare organization’s patient population.

• The philosophy of integrated pharmaceutical care is extended to contract nego-

tiations with payers and other providers to work toward continuity of care. Risk
contracts and contracts with outside vendors are reviewed by management and
modified where possible to ensure effective cross-site communication and
medication management.

• An evaluation of pharmacy costs and other treatment options in relation to their

effectiveness over the long-term. Thus, the purchase cost or per dosage cost for a
given medication is considered only one aspect of the total value of the medica-
tion in evaluating treatment options. Other issues to consider include ease of use
for the patient, history of patient compliance with the medication, total treatment
costs over a longer time interval (e.g., one to five years), research on effectiveness
compared to other drugs or treatments, provider satisfaction, patient satisfaction,
potential side effects, and likelihood or potential of drug interactions.

• The design of the pharmacy benefit would seek to minimize adverse clinical
effects and maximize positive opportunities arising from rules or limitations of
the benefit.

Integrating Pharmaceutical Care: A Vision and Framework 19

Benefits of
Integrated Pharmaceutical Care
Integration of pharmaceutical care with all other care decisions will improve the
effectiveness of therapy in many ways. Providers will diagnose disease and identify
related conditions at an earlier stage so that appropriate therapies can be prescribed
sooner to prevent further deterioration. Interdisciplinary teams of clinicians and
pharmacists and electronic systems that give warning signals at the time of
prescribing will avoid waste and increase satisfaction. Patients who receive better
education about their medications should understand the reasons and the directions
for their therapy more fully—leading to increased compliance and improved clinical
outcomes. Caregivers will improve their communication and feedback. This will
enhance the efficiency of treatment and allow the care provider team to better
monitor the effectiveness of therapy. In turn, this will enable more timely alterations
in therapy for individuals and targeted patient groups.

Healthcare organizations also will realize the benefits of an integrated approach.

A Blue Cross/Blue Shield survey examined how health plans were responding to
increasing pharmaceutical costs and how they were planning to improve their
capabilities over time. The most successful health plans were found to be working
toward a fully integrated patient care approach. In such plans, reporting structures
and staffing allowed for interaction and communication between pharmacy and
other clinical staff, and integrated data capabilities allowed timely access to data
from disparate settings (Boland, 1998).

In theory, a healthcare organization with integrated pharmaceutical care will

• Target high-risk patient groups, especially those requiring multiple medications,
for enhanced management to avoid problems such as adverse drug-to-drug or
drug-to-disease reactions, over or undertreatment of comorbid conditions, and
noncompliance with regimens.
• Provide information to patients and their families and allow them to be partners
in their own healthcare.
• Consider the multidimensional needs and characteristics of patients when
choosing a course of treatment, establishing pharmaceutical policies, and
structuring drug benefits.
• Evaluate pharmaceutical care and track effects.
• Consider the cost of a particular drug or course of treatment as only one factor in
selection of medications; other factors include clinical effectiveness across a
variety of patients, compliance issues, side effects, ease of administration, and
effect on systemwide costs.
• Make information about medications accessible—with appropriate safeguards—
to all providers in all sites of care to support effective decisionmaking.
• Arrange and manage pharmacy services to support care goals through cross-site
communication and interdisciplinary team management.

20 The National Chronic Care Consortium and The National Pharmaceutical Council
 Case Studies
This paper presents concepts and issues in true delivery system integration. But
putting these concepts into practice in the real world can be challenging. Hearing
about other organizations’ experiences regarding barriers and processes for
improvement can be useful for organizations wishing to implement their own
programs. Below are descriptions of current programs that are representative of
best practice prototypes. Common themes in these examples include development
of systems approaches to reduce unnecessary drug use and adverse effects;
management of pharmaceutical care by interdisciplinary teams; strategic use of
pharmacists; coordination of information; development of computerized decision-
support systems; and implementation of an information-based technique for
improving the quality of pharmaceutical care.

Improving Care Processes

An Interdisciplinary Team Approach to Care
At Johns Hopkins Bayview Medical Center, an interdisciplinary team approach,
together with Clinical Practice Improvement (CPI) techniques have changed the
way care is delivered and evaluated. CPI creates a dynamic environment for
improving the process of care, including pharmaceutical care. It involves develop-
ing a consensus of practitioners on the process used for treatment of a given disease
(e.g., drug selection, dosages, timing of administration), measurement of treatment
outcomes, and feedback to the practitioners. Outcomes include effectiveness of
treatment, complications, long-term medical outcomes, patient functional status,
patient satisfaction, and overall treatment costs. A CPI team evaluates this informa-
tion and makes fact-based recommendations on improvements in the process. The
modified process is then implemented, evaluated, and fed back to the practitioners.
Continuous quality improvement is possible by repeating this sequence. Physicians
respond favorably to this evidence-based, non-judgmental approach to improving
quality of care (Buckle et al., 1999; Horn, 1995).

Reducing Adverse Drug Effects

In 1988, LDS Hospital, a division of multihospital Intermountain Health Care (IHC)
in Salt Lake City, implemented a process-of-care approach to the management of
infectious disease. With a focus on the complete continuum of care, the program
uses a computer-assisted decision support system based on practice guidelines
derived from a consensus of local physicians. The guidelines were programmed
into a hospital information system as rules, algorithms, and predictive models. The
LDS antibiotic management process extends far beyond initial product selection and
includes choosing the correct dose and the correct route and timing of
administration for the individual patient. It also takes into account such factors as
current physiological functional status, decisions to obtain cell cultures, laboratory
tests, and duration of therapy.

LDS Hospital evaluated the effects of this integrated care program seven years after
implementation and found that adverse drug events associated with antibiotics
were reduced by 30 percent and mortality declined. In addition, expenditures for

Integrating Pharmaceutical Care: A Vision and Framework 21

antibiotics decreased from 25 percent of total costs in 1988 to 13 percent, although
the number of patients receiving antibiotics increased from 32 percent to 53 percent.
Trend analysis showed that antimicrobial resistance patterns have been stable
(Evans et al., 1998). Since the trial, IHC has implemented the program in many of its
large hospitals, emergency rooms, and outpatient clinics. The antiinfectives
program has been a model for disease management applications in other specialties,
including diabetes, anticoagulants, congestive heart failure, and coronary artery
bypass surgery.

Evidence-Based Prescribing
Challenged by the growth in the size and complexity of healthcare delivery systems
and the increase in pharmaceutical costs, organizations have worked to optimize
the value of pharmaceutical therapy. HealthNet, a 1.4 million member California
HMO, established a data-intensive, computerized decision support system that
allowed providers to practice evidence-based prescribing, often using state-of-the-
art medications. Using company-wide patient care data, HealthNet analyzed and
provided feedback to its medical groups on treatment patterns in 13 disease groups
accounting for 50 percent of drug use. This information enabled HealthNet to
realize overall cost savings and quality improvement, often through the use of more
costly medications (Cunningham, 1997).

A Population-Based Approach
One large-scale intervention that integrated computers, pharmacists, and physicians
was shown to be promising for improving prescribing patterns and supporting a
population-based approach to geriatric care. Focusing on an ambulatory elderly
population, an independent medical advisory board consisting of geriatric
specialists in pharmacy, medicine, and nursing adopted the “gold standard” Beers
criteria for seniors to identify drugs or drug combinations that are inappropriate for
the elderly. These included long-acting sleeping and anti-anxiety agents, short-
acting barbiturates, anticholinergic antidepressants, certain narcotic analgesics,
prescriptions exceeding maximal dosages for the elderly, nonsteroidal anti-
inflammatory drugs for patients with ulcers, and beta-blockers for patients with
chronic obstructive pulmonary disease. Using the online database, provider
prescribing patterns were evaluated for a total of 23,269 older patients receiving
prescription drugs from a large pharmacy benefits manager during a 12-month
timeframe. Potentially inappropriate drug use was identified. Computer alerts
triggered telephone calls to the physicians by pharmacists with training in
geriatrics. During these calls, the pharmacists provided information on the
principles of geriatric pharmacology and on quality of care, based on best practices.
The telepharmacy intervention yielded a contact rate with physicians of 56 percent.
About one quarter of all alerts were accepted by physicians—with a range of 40
percent for one type of drug to two percent for another. (Monane et al., 1998)

Reorganizing Pharmaceutical Care

A Functional Integration Team
Fairview Health Services, a regional healthcare system in Minnesota, grew from a
single hospital to a vertically-diversified multiorganizational healthcare system by
acquiring, building, and consolidating hospitals and developing hospital-based
home care and senior services. However, separate facilities within the

22 The National Chronic Care Consortium and The National Pharmaceutical Council
 organizationcontinued to operate largely independently of each other, including in
the provision of pharmaceutical care.

In 1991, the system’s management was restructured to bring the hospital services
together in one division and the non-hospital services in another division, known as
Continuum Services. In 1995, the many outpatient and retail pharmacies owned
and operated by Fairview participated in a systemwide Medication Management
Task Force to increase quality and control costs by integrating medication
management from the time a decision was made to use a drug to the time it was
administered. In 1997, Fairview began to critically review several key functions,
including how they organized pharmacy services across the system and how they
delivered pharmaceutical care. They established a “functional integration team” of
professionals across the system; this team’s recommendations resulted in a more
centralized management structure and changes to certain aspects of ordering,
distributing, and monitoring medication use. A major focus was to bring the
patient, physician, and pharmacist together to better manage pharmaceutical care
(NCCC Member Information).

A Risk Reduction Program

As part of its quality improvement and performance monitoring program,
Lancaster Health Alliance in Pennsylvania used a transdisciplinary leadership team
to review practices at its 30-bed transitional care unit (TCU). The team discovered
that many TCU residents were taking a large number of medications—outside of a
range considered to be a benchmark for this population. Residents were averaging
15 medications per day, with a range of between 10 and 22 medications daily.
Furthermore, the use of antipsychotic medications seemed high.

The leadership team began a Risk Reduction Program and launched a

multipronged approach to addressing polypharmacy; this approach included
highlighting the role of clinical pharmacists in physician education, researching and
publishing geriatric dosage guidelines, presenting data on polypharmacy and its
effects, and working with nurses and nursing leaders to address dosage adjustment
and improve inservice education. The team then focused attention on the use of
antipsychotic medications. A clinical pharmacist with knowledge of the elderly
provided leadership in planning and oversight, helping to guide appropriate use.
Nursing and physician staff participated in educational sessions. The organization
also established a performance improvement monitoring process for effectiveness
and appropriateness of psychoactive medication use. Subsequently, the clinical
pharmacist collaborated with the chairman of the Department of Psychiatry to
develop systemwide standards for antipsychotic drug use in the geriatric
population, using data gathered from the subacute care study.

Results were dramatic. Overall medication use dropped to an average of 8.1

medications per resident per day, and the number of residents on psychoactive
medications dropped from 15 to three over a 22-month period. Furthermore, there
was a reduction in the use of restraints (from five people with restraints to zero use
of restraints after November 1997). Unexpected positive outcomes included the
reduction in the number of medication errors seen within the unit, perhaps due to
fewer medications being given, and a heightened awareness of medication
dispensing and administration on the unit. (Fridy, 1998)

Integrating Pharmaceutical Care: A Vision and Framework 23

Changing Organizational and Reporting Structures
In the 1980s, Sharp HealthCare, a regional healthcare system in San Diego, grew
from a single hospital to a group of hospitals and then to a hospital system with
medical clinics and other facilities. However, like Fairview Health Services, the
organization operated more as a collection of individual facilities than as a single
system of care. Beginning in 1994, management worked to reengineer the
organizational and reporting structures with the objective of creating an integrated
system. This process allowed staff pharmacists to move into unconventional roles
and to participate as decisionmakers in clinical care. Sharp created a steering
committee to oversee the development and refinement of a systemwide approach to
pharmaceutical care. Functional teams reporting to the steering committee worked
to standardize policies and procedures. As of 1996, Sharp was working toward
creating a systemwide Pharmacy and Therapeutics Committee to review guidelines
for drug use and evaluate formularies (Rizos et al., 1996).

Involving Pharmacists in Care Delivery

Pharmacists and Physician Partnerships
A pilot project at Allina Health System in Minnesota has shown positive results
among older adults seen at one of two clinics; these results included reducing
polypharmacy and improving effectiveness of medications by selecting medication
regimens designed for easy compliance and by identifying other user-friendly
methods for elderly patients. The program partnered pharmacists with primary care
physicians and targeted patients with congestive heart failure. A total of 167 patients
were enrolled during a four month to 10 month timeframe. Results included
• Improvement in laboratory values in patients receiving anticoagulation therapy
• Decreased risk of cerebrovascular events in patients receiving hyperlipidemia
therapy
• Changes in medication, dosage, or reduction in number of medications due to
comprehensive medication review by pharmacist/physician team
• Increased number of low-income patients receiving assistance in meeting
medication needs through pharmaceutical company free drug programs
Despite recommendations which increased drug costs, many recommendations
resulted in cost savings—not including the potential cost savings and improved
patient satisfaction from reducing the risk of cardiac events. Allina plans to continue
the work at its Senior Health Clinic, tracking outcomes for a greater length of time
and potentially adding an additional site (NCCC Member Information).

An Integrated Approach to Medication Management

A pilot program at the Sepulveda Veterans Affairs Medical Center in California
offers an example of the use of pharmacists in an integrated approach to medication
management. Pharmacists made home visits to evaluate medications for a group of
frail older people. Patients were found to be taking a mean of 4.7 medications,
although a mean of 6.0 were prescribed. Evaluations also revealed consumption of
many potentially unnecessary medications (found in 70 percent of subjects) and
multiple problems with the medication regimens (e.g., incorrect drug frequency or
dosage, expired medications, medication omissions). Follow-up after the visit, which
included patient counseling and recommendations to the prescriber, showed a
significant decrease in medication problems (Hsia Der et al., 1997).

24 The National Chronic Care Consortium and The National Pharmaceutical Council
 Taking Action
Integrated pharmaceutical care is not going to happen immediately. Change,
particularly systems reform, is an ongoing process. The following tasks may be
helpful in transforming pharmaceutical care to be more commensurate with
problems of chronic disease and disability.

1. Review current practices.

Examine how your system organizes pharmaceutical services and delivers
pharmaceutical care, paying particular attention to care continuity across
settings/programs. Conduct a base analysis of current practices on sources of
information, including patients, physicians, pharmacists, and other key
constituents, as well as data on drug use, adverse drug events, and other key
statistics. If a patient group is particularly at risk for high medication use (e.g.,
frail elderly diabetics), consider focus groups or one-on-one patient interviews to
better understand pharmaceutical issues from the client perspective.

2. Identify strengths and challenges.

Identify key strengths and problem areas in pharmaceutical care within the
organization. Prioritize areas of focus. Adopt short-term and long-term goals.

3. Examine best practices.

Examine best practices and innovations in pharmaceutical care for your key focus
areas. Conduct a literature search and telephone interviews or site visits to other
organizations.

4. Select initiatives.
Select one or two initiatives that have broad support and defined, measurable
goals. Initiatives may be focused on building the organization’s infrastructure
(e.g., improving cross-site transfer of pharmacy data over several settings in real
time) or on delivering pharmaceutical care more effectively (e.g., for a defined
frail older adult client base, building interdisciplinary teams of care providers
that include a pharmacist trained in working with older adults).

5. Provide appropriate resources.

Ensure that the pharmaceutical care initiative is appropriately financed.

Integrating Pharmaceutical Care: A Vision and Framework 25

6. Track progress.
Ensure that progress is tracked through accurate data collection.

7. Communicate results.
Make sure your organization communicates the results of your efforts across the
organization. For long-term efforts, communicate interim findings.

8. Evaluate your success.

Evaluate the success of your pharmaceutical initiatives to determine if they
should be expanded, modified, or dropped. Identify key learnings and apply
them to future efforts.

9. Determine next-stage priorities.

With input from key stakeholders, determine your next steps in moving toward
the vision of integrated pharmaceutical care.

Integrated Pharmaceutical Care Toolbox

The NCCC and NPC have developed a toolbox to assist healthcare organizations in
examining and evaluating their current pharmaceutical care practices. Integrating
Pharmaceutical Care is a toolbox designed to allow a multiorganizational healthcare
system to analyze its own progress toward integrated pharmaceutical care—across
settings and facilities—according to certain guiding principles and measurable
objectives.

The toolbox provides a framework and lays out a suggested process for conducting a
self-assessment. The centerpiece of this toolbox is the Criteria and Measures for Integrated
Pharmaceutical Care. Working with a group of physicians, pharmacists, and
administrators, the NCCC and the NPC developed these criteria and measures to define
targets for healthcare organizations to use in moving toward a more integrated approach
to providing pharmaceutical care.

For more information about this toolbox, call the NCCC at (612) 858-8999.

26 The National Chronic Care Consortium and The National Pharmaceutical Council
 References
Balkrishnan, R. “Predictors of Medication Adherence in the Elderly.” Clinical Therapy 20 (4): 764–771
(1998).

Baum, C., D.L. Kennedy, M.B. Forbes, and J.K. Jons. “Drug Use in the United States in 1981.” Journal of
the American Medical Association 251 (1984): 1293–1297.

Boland, B. “The Evolution of Best-in-Class Pharmacy Management Techniques.” Journal of Managed

Care Pharmacy 4 (4): 364–373 (1998).

Bringewatt, R.J. “Integrating Care for People with Chronic Conditions.” Bloomington: National
Chronic Care Consortium, 1995.

Buckle, J., P. Myirski, and M. Myers. “Quality Improvement: A Medical Center’s Successful Care
Management Program.” Drug Benefit Trends February (1999): 40–48.

Cohen, K.R. and D.H. Naughton. “Patient-Centered Care: A Revolution in Medicine.” Medical Interface
June (1995): 66–73.

Col, N., J.E. Fanale, and P. Kornhom. “The Role of Medication Noncompliance and Adverse Drug
Reactions in Hospitalizations in the Elderly.” Archives of Internal Medicine 150 (1990): 841–845.

Coons, S.J., et al. “Predictors of Medication Noncompliance in a Sample of Older Adults.” Clinical
Therapy 16 (1994): 110–117.

Cunningham, R. “Options vs. Limits: Drug Cost Strategies Reconsidered.” Perspectives on Medicine and
Health September 29 (1997).

Cystic Fibrosis Foundation. “Rationale for the Use of Human Deoxyribo-Nuclease 1 (rhDNase-
Pulmozyme) in Patients with Cystic Fibrosis.” Consensus Conference Vol IV, Sec 1, Sept. 22, 1993.

Detels, R., et al. “Effectiveness of Potent Antiretroviral Therapy on Time to AIDS and Death in Men
With Known HIV Infection Duration.” Journal of the American Medical Association 280 (17): 1497–1503
(1998).

Evans, R.S., S.L. Pestotnick, D.C. Classen, S.D. Horn, S.B. Bass, and J.P. Burke. “Preventing Adverse
Drug Events in Hospitalized Patients.” Annals of Pharmacotherapy 28 (1994): 523–527.

Evans, R.S., et al. “Prevention of Adverse Drug Events Through Computerized Surveillance.”
Proceedings of the Annual Symposium of Computer Applications in Medical Care: 1992.

Evans, R.S., et al. “A Computer Assisted Management Program for Antibiotics and Other Antiinfective
Agents.” New England Journal of Medicine 338 (1998): 232–238.

Fagan, S.C., et al. “Cost-effectiveness of Tissue Plasminogen Activator for Acute Ischemic Stroke.”
Neurology 50 (1998): 883–889.

Fridy, N. “A Transdisciplinary Risk Reduction Program That Can Work for You.” Subacute Care Today
September/October (1998): 24–31.

General Accounting Office. “Prescription Drugs in the Elderly.” Washington, D.C.: GAO/HEHS-95-
152, 1995.

Gevirtz, F., R.R. Corrato, P. Chodoff, D.B. Nash. “Chronic Disease, Women’s Health and “Disease
Management”: The Latest Trend?” Women’s Health Care Issues 9 (1): 18–29 (1999).

Greenberg, R.N. “Overview of Patient Compliance with Medication Dosing: a Literature Review.”
Clinical Therapy 6 (1984): 592–599.

Hendee, W.R. “Overview.” Second Annenberg Conference on Enhancing Patient Safety and Reducing
Errors in Health Care. Annenberg Center for Health Sciences at Eisenhower. Rancho Mirage, CA,
November 8-10, 1998.

Horn, S.D., P.D. Sharkey, and C. Phillips-Harris. “Formulary Limitations and The Elderly: Results from
the Managed Care Outcomes Project.” American Journal of Managed Care 4 (8): 1105–1113 (1998).

Horn SD: CPI: “Improving Quality and Decreasing Cost in Managed Care.” Medical Interface. July,
1995: 60-64, 70.

Integrating Pharmaceutical Care: A Vision and Framework 27

Hsia Der, E., L.Z. Rubenstein, and G.S. Choy. “The Benefits of In-home Pharmacy Evaluation for Older
Persons.” Journal of the American Geriatrics Society 45 (2): 211–214 (1997).

James, B., Executive Director for Health Care Delivery Research, Intermountain Health Care. Interview
with staff of the President’s Advisory Commission on Consumer Protection and Quality in the Health
Care Industry, January 9, 1998.

Leape, L., et al. “Systems Analysis of Adverse Drug Events.” Journal of the American Medical Association
274 (1): 35–43 (1995).

Legg, R.F., et al. “Cost-effectiveness of Sumatriptan in a Managed Care Population.” American Journal of
Managed Care 3 (1): 117–122 (1997).

Legg, R.F., et al. “Cost benefit of Sumatriptan to an Employer.” Journal of Occupational and Environmental
Medicine 39 (7): 652–657 (1997).

Levy, R.A. and D. Cocks. Component management fails to save health care system costs, the case of restrictive
formularies. Second edition. Reston, VA: The National Pharmaceutical Council, 1999.

Lindley, C.M., M.P. Tully, V. Paramsothy, and R.C. Tallis. “Inappropriate Medication is a Major Cause of
Adverse Reactions in Elderly Patients.” Age and Aging 21 (1992): 294–300.

McLaughlin, T.J., et al. “The Effect of Comorbidity on Use of Thrombolysis or Aspirin in Patients with
Acute Myocardial Infarction Eligible for Treatment.” Journal of General Internal Medicine 12 (1997): 1–6.

Monane, M., et al. “Improving Prescribing Patterns for the Elderly Through an Online Drug Utilization
Review Intervention.” Journal of the American Medical Association 280 (14): 1249–1252 (1998).

Mueller, C., C. Schur, and J. O’Connell. “Prescription Drug Spending: The Impact of Age and Chronic
Disease Status.” American Journal of Public Health 87 (10): 1626–1629 (1997).

National Health Information. “HIV Treatment Strategies Must Shift to DM Focus.” Healthcare Demand
and Disease Management 4 (10): 145–160 (1998).

Ogden, J.E., A. Muniz, A.A. Patterson, D.J. Ramirez, and K.W. Kizer. “Pharmaceutical Services in the
Department of Veterans Affairs.” American Journal of Health System Pharmacists 54 (1997): 761–765.

Peters, W.P. “Comparative Effects of GM-CSF and PBPC chemotherapy.” Blood 81 (7): 1709–1719 (1993).

Pierpaoli, P.G., R.W. Anderson, W.N. Kelly, A. Linggi, and L.D. Pelham. “Strategic Planning for Clinical
Services: Panel Discussion.” American Journal of Hospital Pharmacists 43 (9): 2174–2177 (1986).

Reeder, C.E., C.M. Kozma, and C. O’Malley. “ASHP Survey of Ambulatory Care Responsibilities of
Pharmacists in Integrated Health Systems.”American Journal of Health System Pharmacists 55 (1998): 35–
43.

Redelmeier, D.A., H.T. Siew, and G.L. Booth. “The Treatment of Unrelated Disorders in Patients with
Chronic Medical Diseases.” New England Journal of Medicine 338 (21): 1516–1520 (1998).

The Robert Wood Johnson Foundation. Chronic Care in America, a 21st Century Challenge. The Robert
Wood Johnson Foundation: Princeton, 1996.

Soumerai, S.B., D. Ross-Degnan, J. Avorn, T.J. McLaughlin, and I. Choodnovsky. “Effects of Medicaid
Drug-Payment Limits on Admission to Hospitals and Nursing Homes.” New England Journal of Medicine
325 (1991): 102–107.

Soumerai, S.B., T.J. McLaughlin, D. Ross-Degnan, C.S. Casteris, and P. Bollini. “Effects of Limiting
Medicaid Drug Reimbursement Benefits on the Use of Psychotropic Agents and Acute Mental Health
Services by Patients with Schizophrenia.” New England Journal of Medicine 331 (1994): 650–655.

Stewart, R.B., M.T. Moore, F.E. May, R.G. Marks, and W.E. Hale. “A Longitudinal Evaluation of Drug
Use in an Ambulatory Elderly Population.” Journal of Clinical Epidemology 44 (12): 1353–1359 (1991).

Stewart, R.B. and J.W. Cooper. “Polypharmacy in the Aged: Practical Solutions.” Drugs and Aging 6
(1994): 449–461.

Stocker, M.A. Quotation from Michael A. Stocker, President and CEO of Empire Blue Cross and Blue
Shield (NY). Wall Street Journal July 12, 1996.

Wilcox, S.M., D.U. Himmelstein, and S. Woolhander. “Inappropriate Prescribing for the Community-
Dwelling Elderly.” Journal of the American Medical Association 272 (1994): 292–296.

28 The National Chronic Care Consortium and The National Pharmaceutical Council
 Acknowledgements
The NCCC and NPC acknowledge the contributions of Jean Polatsek who reviewed this
document and the staffs of the NCCC and NPC who provided support for its publication.

Authors
Richard J. Bringewatt is President and CEO of the National Chronic Care Consortium
(NCCC). Mr. Bringewatt developed the “chronic care network” strategy that is central to the
NCCC’s work and assumed the lead role in developing the NCCC. During his 29-year career,
Mr. Bringewatt has developed and managed numerous healthcare programs including
establishing a multidisciplinary clinic, a senior HMO, and a variety of other primary, acute,
and long-term care programs for the chronically ill. He has also provided leadership in
health systems policy development at the county, state, and federal levels. A national expert
on chronic care, Mr. Bringewatt has provided testimony on Medicare reform before the
United States House Ways and Means Committee and has consulted with many of the
nation’s leading demonstrations in chronic care.

Richard Levy, Ph.D., is Vice President of Scientific Affairs for the National Pharmaceutical
Council (NPC) and is responsible for research planning, development, and coordination. His
current research interests center on issues related to achieving optimal value of medications.
Specific research areas include the role of pharmaceuticals in organized healthcare systems,
issues in geriatric pharmacotherapy, patient noncompliance with medications, and clinical
and economic aspects of pharmaceutical benefits programs. Dr. Levy has spent more than 30
years teaching, writing, and conducting research in universities and private industry and is
the author of more than 70 publications in pharmacology and health services research.

Deborah Paone serves as the National Chronic Care Consortium's Senior Research Associate,
providing leadership in developing practice-based products and resources on systems
integration across the full continuum of primary, acute, and long-term care settings/services.
Ms. Paone serves as consultant to the State of Minnesota on their dually eligible
demonstration (Minnesota Senior Health Options). She also works with member committees
on operational and strategic issues in coordinating care across settings and over time.

National National
Chronic Care Pharmaceutical
Consortium Council
National Chronic Care Consortium National Pharmaceutical Council
8100 26th Avenue South 1894 Preston White Drive
Suite 120 Reston, VA 20191-5433
Bloomington, MN 55425 (703) 620-6390
(612) 858-8999 Fax: (703) 476-0904
Fax: (612) 858-8982 www.npcnow.org.
www.nccconline.org

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